Introduction. Ashford and St Peter's Hospital (ASPH) is a district general hospital in Chertsey, Surrey. It is a tertiary referral unit offering a circular frame service to manage complex trauma patients in the South East of England. This study analyses the patient pathway in 66 consecutive tertiary referrals from 2015–2020. All patients were managed with an Ilizarov frame for either a tibial plateau fracture or pilon fracture. Materials and Methods. The patient journey of 66 consecutive tertiary referrals for tibial plateau and pilon fractures were analysed. The following data was captured: patient demographics; type of injury; referring centre; date of injury; date of referral; date of arrival at ASPH; date of surgery and date of discharge. Using this data we aimed to identify areas of the pathway that can be improved. In addition, the 66 patients were split into two groups of 33 patients. 33 patients were referred via an electronic referral platform and 33 patients were referred verbally prior to the implementation of the electronic referral platform. The groups were compared to see the impact of an electronic referral platform on the patient's journey. Results. Average age 45 (range 17–88 years), Male percentage 54.55%, 45 tibial plateau patients, 21 pilon patients. Injury to Admission at ASPH- 6 days (median), Injury to Surgery 8 days (median), Surgery to Discharge 4 days (median), Total stay in ASPH 6 days (median). Conclusions. The biggest delay in our tertiary referral pathway is from referral to arrival at ASPH. The implementation of an electronic referral pathway has not improved times from referral to arrival at ASPH. Ring fenced beds for tertiary referrals would be the greatest way to improve flow through the pathway and reduce the complications related to delayed surgery

Wrist arthrodesis is a common surgical procedure that provides a high level of functional outcome and pain relief among patients.[1] Upon partial arthrodesis, the wrist experiences changes in load transmission that are influenced by the type of arthrodesis performed. Measuring the load through the wrist joint is difficult, however, combined with computational models [2], it is possible to obtain data regarding the load mechanics of the wrist joint. Although successful fusion rates among patients have been reported, it remains unclear what the biomechanical consequences are. The aim of the study is to quantify pre and post operative load transmission through a cadaveric wrist which has undergone simulated arthrodesis of the radiolunate(RL) joint. An embalmed human wrist was dissected dorsally exposing distal radius, radiocarpal and carpometacarpal joints, and dorsal ligaments. The radioscaphoid(RS) ligament was sacrificed to accommodate insertion of a PPSEN-09375 force sensitive resistor (FSR) into the RS joint. The FSR was calibrated prior to measuring the contact force on the RS joint. The wrist was aligned in the neutral position in cardboard piping, and secured proximally and distally with Dental Plaster (OthoBock Healthcare Plc, Surrey, UK). The midsection of piping was windowed to permit placement of the FSR in the RS joint, and fixation of the RL joint using 2 Kirschner wires. The window was completed circumferentially and the specimen was placed in the Instron where a graduated axial compression was applied at 20 N/min. The results showed that when the radiolunate joint is fused, and a total axial load of 100N is applied, the load transmitted through the RS joint was approx 65N. i.e. 65% of the force. This is greater than the 56% measured experimentally by Blevens et al (1989) in an unfused specimen[3]. We plan to repeat our measurements and compare to an untreated cadaveric wrist

Introduction. Plantar fasciopathy is a common cause of heel pain, and is usually treated in primary practice with conservative measures. Intractable cases can prove very difficult to treat. Currently plantar fasciopathy is not routinely imaged and treatment is empirical. At the Royal Surrey County Hospital patients with intractable plantar fasciopathy are managed in a unique ‘one-stop’ Heel Pain clinic. Here they undergo clinical assessment, ultrasound scanning and targeted therapy. Methods. Patients referred to the clinic since 2009, with symptoms lasting longer than 6 months and failed conservative management, were prospectively followed. Plantar fasciopathy was confirmed on ultrasound scanning. The ultrasound scans were used to classify the disease characteristics of the plantar fascia. Results. 125 feet (120 patients) were found to have plantar fascia disease. Ultrasound scans demonstrated 64% with typical insertional pathology only. The remaining 36% had atypical distal fascia involvement, with either pure distal disease or a combination of insertional and distal disease. Patients with atypical distal disease were found to have either distal thickening or discrete fibromata. Conclusion. The high proportion of atypical (non-insertional) disease in this cohort shows that ultrasound scanning is valuable in determining location and characterising the pathology in the plantar fascia. Atypical pathology would otherwise not be detected. We propose a new classification for plantar fasciopathy; insertional fasciopathy or non-insertional fasciopathy. This is in keeping with current classification of achilles tendinopathy. The main benefit of this Guildford Classification is in determining optimum treatments for recalcitrant plantar fasciopathies. Empirical treatment is not adequate for recalcitrant cases

The performance of total knee arthroplasty in deeply flexed postures is of increasing concern as the procedure is performed on younger, more physically active and more culturally diverse populations. Several implant design factors, including tibiofemoral conformity, tibial slope and posterior condylar geometry have been shown directly to affect deep flexion performance. The goal of this study was to evaluate the performance of a fixed-bearing, asymmetric, medial rotation arthroplasty design during kneeling activities. Thirteen study participants (15 knees) with primary total knee arthroplasty (Medial Rotation Knee, Finsbury, Surrey, UK) were observed while doing a step activity and kneeling on a padded bench from 90° to maximum comfortable flexion using lateral fluoroscopy. Subjects averaged 74 years of age and nine were female. Subjects were an average of 17 months post-operative, and scored 94 points on the International Knee Score and 99 on the Functional Score. Digitised fluoroscopic images were corrected for geometric distortion and 3D models of the implant components were registered to determine the 3D position and orientation of the implants in each image. During the step activity, the medial and the lateral femoral contact point stayed fairly constant with no axial rotation from 0 to 100° of flexion. At maximum kneeling flexion, the knees exhibited 119° of implant flexion (101°-139°), 7° (-7° to 17°) tibial internal rotation, and the lateral condyle translated backwards by 11 mm. Patients with medial rotation knee arthroplasty exhibited medial pivot action with no paradoxical translation. The knees exhibited excellent kneeling flexion and posterior translation of the femur with respect to the tibia. The axial rotation in MRK was within the range of normal knee kinematics from -10 to 120 (perhaps 140)

Background. Since the development of modern total hip replacement (THR) more than 50 years ago, thousands of devices have been developed in attempt to improve patient outcomes and prolong implant survival. Modern THR devices are often broadly classified according to their method of fixation; cemented, uncemented or hybrid (typically an uncemented acetabular component with a cemented stem). Due to early failures of THR in young active patients, the concept of hip resurfacing was revisited in the 1990's and numerous prostheses were developed to serve this patient cohort, some with excellent clinical results. Experience with metal-on-metal (MoM) bearing related issues particularly involving the ASR (DePuy Synthes, Warsaw, Indiana) precipitated a fall in the use of hip resurfacing (HR) prostheses in Australia from a peak of 30.2% in 2004 to 4.3% in 2015. The effects of poorly performing prostheses and what is now recognised as suboptimal patient selection are reflected in the AOANJRR cumulative percent revision (CPR) data which demonstrates 13.2% revision at 15 years for all resurfacing hip replacements combined; with 11 different types of hip resurfacing prostheses recorded for patients less than 55 years of age and a primary diagnosis of OA. When this data is restricted to only those prostheses currently used in Australia (BHR; Smith and Nephew, Birmingham, UK & ADEPT; MatOrtho Ltd, Surrey, UK) there is a CPR of 9.5% at 15 years for all patients. Despite these CPR results, recognition is emerging of the important distinction between MoM THR and resurfacing. Furthermore, in light of current consensus for patient selection and the surgical indications for resurfacing, a gender analysis demonstrates a CPR for females of 14.5% at 10 years compared to 3.7% for males. Similar difference for head size >50mm with 6% CPR at 10 years compared to 17.6% for head size <50mm (HR=2.15; 1.76, 2.63; p<0.001). Leading to renewed interest in resurfacing particularly in the young, active male. In addition to registry based CPR data, several studies have concluded that a true difference in mortality rates between HR and other forms of THR exists independent of age, sex or other confounding factors. We hypothesised that a difference in adjusted mortality rates between HR and other forms of THR may also be present in the Australian population. We undertook an ad hoc data report request to the AOANJRR. The data set provided was deidentified for patient, surgeon and institution and included all HR and conventional THR procedures performed for the diagnosis of primary osteoarthritis recorded in the Registry since inception in 1999. We requested mortality and yearly cumulative percent survival (CPS) of patients for primary HR and THR with sub-group analysis by the mode of fixation. There were 12,910 hip resurfacings (79% male) compared to 234,484 conventional THR (46.8% male) over the study period. When adjusted for age and gender over the 15 years of available data, there was a statistically significant difference in cumulative percent survival (CPS) between conventional THR and hip resurfacing (HR 1.66 (1.52, 1.82; p<0.001)) and between cemented THR and hip resurfacing (HR 1.96 (1.78, 2.43; p<0.001)); between uncemented THR and hip resurfacing (HR 1.58 (1.45, 1.73; p<0.001)); and between hybrid THR and hip resurfacing (HR 1.82 (1.66, 1.99; p<0.001)). When adjusted for age, gender and ASA over the 3 years data available, there was no statistically significant difference in CPS between hip resurfacing and any individual fixation type of THR. Discussion. The results demonstrate a statistically significant adjusted survival advantage for hip resurfacing compared to conventional THR and between fixation methods for THR. These findings are consistent with previous studies. While a difference in adjusted mortality rate appears to exist, we are yet to definitively determine the complex interplay of causative factors that may contribute to it

Heel pain is very prevalent. Pain, especially after a period of rest, is the main symptom. Reduced ability to walk long distances and inability to participate in exercise and sport are other complaints. Plantar heel pain is most commonly caused by plantar fasciitis. Whilst only the recalcitrant cases reach secondary care, this can still be a significant workload. In the Royal Surrey County Hospital, Guildford, we see approximately 200 cases of recalcitrant heel pain each year. The vast majority of cases never come to hospital and are managed in primary care (1500/yr in podiatry alone). Effective primary treatments should reduce the number of long-term sufferers. Recalcitrant cases of plantar fasciitis often have atypical symptoms. Radiological imaging is extremely useful in clarifying the diagnosis. Ultrasound is our preferred modality. There is a spectrum of pathology that affects the plantar fascia, and this is less well classified than for the achilles tendon, where the distinction between insertional tendinopathy and tendinopathy of the main body of the tendon is helpful in guiding treatment. The evidence for many forms of treatment for plantar fasciitis is weak. Currently, the use of formal calf stretching programs is widely considered to be the best first-line treatment. There are additional benefits with stretches to the fascia itself. The mechanism by which these stretches help is not well established. Calf contracture is, however, associated with a variety of clinical problems in the foot and ankle. This is especially true for isolated gastrocnemius contracture. There is also laboratory evidence that increased plantar fascia strain is seen with increased calf muscle tension. Surgery to release a gastrocnemius contracture improves biomechanics and has been used in refractory cases of heel pain with good effect. Radial extracorporeal shock wave lithotripsy is the latest version of this non-invasive treatment. Results in our centre are encouraging. For selected cases of atypical plantar fasciopathy injection treatments are effective

Aims

The number of females within the speciality of trauma and orthopaedics (T&O) is increasing. The aim of this study was to identify: 1) current attitudes and behaviours of UK female T&O surgeons towards pregnancy; 2) any barriers faced towards pregnancy with a career in T&O surgery; and 3) areas for improvement.

Aims

Dystrophic calcification (DC) is the abnormal appearance of calcified deposits in degenerating tissue, often associated with injury. Extensive DC can lead to heterotopic ossification (HO), a pathological condition of ectopic bone formation. The highest rate of HO was found in combat-related blast injuries, a polytrauma condition with severe muscle injury. It has been noted that the incidence of HO significantly increased in the residual limbs of combat-injured patients if the final amputation was performed within the zone of injury compared to that which was proximal to the zone of injury. While aggressive limb salvage strategies may maximize the function of the residual limb, they may increase the possibility of retaining non-viable muscle tissue inside the body. In this study, we hypothesized that residual dead muscle tissue at the zone of injury could promote HO formation.

Objectives

The exact aetiology and pathogenesis of microdamage-induced long bone fractures remain unknown. These fractures are likely to be the result of inadequate bone remodelling in response to damage. This study aims to identify an association of osteocyte apoptosis, the presence of osteocytic osteolysis, and any alterations in sclerostin expression with a fracture of the third metacarpal (Mc-III) bone of Thoroughbred racehorses.

Objectives

We investigated the reliability of the cobalt-chromium (CoCr) synovial joint fluid ratio (JFR) in identifying the presence of a severe aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL) response and/or suboptimal taper performance (SOTP) following metal-on-metal (MoM) hip arthroplasty. We then examined the possibility that the CoCr JFR may influence the serum partitioning of Co and Cr.

Objectives

We have encountered patients who developed large joint fluid collections with massive elevations in chromium (Cr) and cobalt (Co) concentrations following metal-on-metal (MoM) hip arthroplasties. In some cases, retrieval analysis determined that these ion concentrations could not be explained simply by the wear rates of the components. We hypothesized that these effects may be associated with aseptic lymphocyte-dominated vasculitis-associated lesion (ALVAL).

Objectives

Secondary fracture healing is strongly influenced by the stiffness of the bone-fixator system. Biomechanical tests are extensively used to investigate stiffness and strength of fixation devices. The stiffness values reported in the literature for locked plating, however, vary by three orders of magnitude. The aim of this study was to examine the influence that the method of restraint and load application has on the stiffness produced, the strain distribution within the bone, and the stresses in the implant for locking plate constructs.

Objectives

The aims of this piece of work were to: 1) record the background concentrations of blood chromium (Cr) and cobalt (Co) concentrations in a large group of subjects; 2) to compare blood/serum Cr and Co concentrations with retrieved metal-on-metal (MoM) hip resurfacings; 3) to examine the distribution of Co and Cr in the serum and whole blood of patients with MoM hip arthroplasties; and 4) to further understand the partitioning of metal ions between the serum and whole blood fractions.

The October 2015 Research Roundup360 looks at: Wasted implants; Biofilms revisited; Peri-operative anticoagulation not required in atrial fibrillation; Determinants in outcome following orthopaedic surgery; Patient ‘activation’ and outcomes; Neuroplasticity and nerve repair; KOOS Score in predicting injury?